Overview

Bipolar Disorder (BD) is a psychiatric term referring to severe and often disabling problems with mood, energy and activity. Bipolar and related disorders are characterised by the presence of manic or hypomanic episodes, with some disorders also characterised by the experience of depressive episodes. For some people, BD is a relapsing condition with distinct episodes of disorder; others have a more chronic course. There is currently no cure for these problems, and BD is typically a life-long diagnosis. However, with appropriate psychopharmacological and psychological treatment, BD is often well managed and the individual is able to maintain good quality of life.

Like most mental disorders, the phenomena of BD are probably quantitative, and more about severity and impairment than merely the presence or absence of symptoms. Nonetheless, most research into the phenomena of BD has been through the lens of the categorical psychiatric diagnosis of BD. DSM-5 describes three primary BD diagnoses – bipolar I disorder (BD I), bipolar II disorder (BD II) and cyclothymic disorder (as well as BD linked to substance use/medication and due to other medical conditions).

BD I is diagnosed on the basis of a single, current or past manic episode (described below), which may be preceded and/or followed by major depressive or hypomanic episodes.

BD II is diagnosed on the basis of a single current or a past hypomanic episode and a current or past major depressive episode.

Cyclothymic disorder is characterised by chronic fluctuating moods with numerous periods of hypomanic symptoms and depressive symptoms, neither of which meet criteria for diagnosable episodes.

Significant psychological distress and/or impairment in functioning are essential for a diagnosis, and indicate the need for psychological or psychiatric evaluation.

The causes of BD’s development and course are complex, multi-factorial and remain poorly understood.1 The condition is strongly heritable2, and like other complex psychiatric phenotypes, heritability appears to result from multiple genes of small effect interacting with each other and the environment.3 Environmental factors are receiving growing research attention, and family of origin stress, abuse, and illicit drug use, are likely causal candidates.4, 5 Other factors considered important in the onset or course of BD include life stress, disrupted circadian and sleep rhythms, dysregulation of neurotransmitter pathways, and decreased connectivity between brain structures thought to be involved in the moderation of emotion.6, 7

Assessment for BD requires taking a thorough history, including personal, family and substance use history, and conducting a thorough symptom review including possible past manic, hypomanic, and depressive episodes. Assessing current substance use and referring the client for a medical review are recommended to assist in differential diagnosis and ensuring no medical basis for the presenting symptoms.

Psychometric assessment instruments for exploring the patient’s current experience have traditionally focussed on the symptoms of mania and depression but it is now recognised that complementary assessment of psychosocial functioning and subjective quality of life is critical for effective engagement and optimal outcomes.8

Research strongly supports the use of mood stabilising medications as first-line treatment, but adding psychosocial interventions to medication regimens improves clinical and functional outcomes.9 These ‘adjunctive’ psychological interventions include educating the client and family about bipolar disorder and supporting adherence to the prescribed medication regimen, addressing personal and lifestyle factors which may precipitate episodes (such as the use of substances, and adverse influences on sleep-wake and social rhythms), reengaging or maintaining social, familial and occupational roles, developing skills around relapse identification and prevention, coping and stress management, improving skills for emotion regulation including effective communication, and critiquing unproductive thoughts and beliefs.10

BD can be associated with substantial impairment and risk of suicide and therefore risk must be evaluated, monitored, and addressed through safety planning. Working closely with family and other support people, and with the prescribing practitioner is highly recommended.

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